Eric is a 55 year-old man, who recently started training for marathon. He used to play tennis. He believed that he would be an excellent marathon runner. He got up around 5AM, run about 2 hours, then went to work. He runs about 5 to 6 days per week. Recently, he had a slight fall during training, he heard pop sound, and immediately felt pain and swelling on right back of the ankle. The pain was sharp, he was unable to walk. He called his PCP right away. He was referred to orthopedic physician. By careful examination, he was suspected to have Achilles tendon tear. MRI was done, which showed right Achilles partial tear. He was advised to stop marathon training, and ice was put at the right Achilles tendon. He was instructed to have rest for one month, wait and see, in the mean time, using ice massage three times a day for 10 min of each, if the tendon is not healed, he might need surgery to repair the tendon.

After two months of the incident, the patient came to me and reported his right ankle is still painful and mild swelling. He was told by his orthopedic doctor that his Achilles tendon is healing, it is not necessary to have surgery. However, he still felt a lot of pain, he only could walk for one block without pain. He tried ice massage and rest another month, he still felt severe pain at right back of the ankle. Therefore, he came to me for eval and treatment.

By physical examination, I saw a swelling and tender Achilles tendon at right with some floating fluid inside. I palpated the ankle, there was some kind of tenderness and the patient was unable to make a full range of motion at right ankle. I believed that the patient was suffering Achilles Tendonitis.

Achilles tendon is the tendon located at back of the ankle that connects calf muscles at the back of the lower leg to the heel bone. Achilles tendon is the thickest and strongest tendon in the body. The Leg muscles are the most powerful muscle group in the body. The contraction of calf muscles pulls the Achilles tendon upward, which pushes the foot downward and gives the power of standing on the toes, walking, running, and jumping. Each Achilles tendon sustains a person’s entire body weight with each step. Depending upon speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subject to up to 3-12 times a person’s body weight during a sprint or push off.

Qualitative and quantitative histological analyses in one study showed that the Achilles tendon has a poor blood supply throughout its length, as determined by the small number of blood vessels per cross-sectional area, which do not in general vary significantly along its length. In light of these findings, it is suggested that poor vascularity may prevent adequate tissue repair following trauma, leading to further weakening of the tendon.

1. Achilles tendonitis is inflammation of the Achilles tendon. Repetitive eccentric overload causing inflammation and microtears of the tendon. However, recently some researches discovered that most people with Achilles injury besides Achilles tendon rupture have Achilles teninosis, rather than Achilles tendonitis because there is no evidence of inflammation at Achilles tendon, the cells at the Achilles tendon are disorganized, degenerated and scarred. But most people in medical field still call it Achilles tendonitis.

Achilles tendonitis is often a running injury or other sport-related injury resulting from overuse, intense exercise, jumping, or other activities that strain the tendon and calf muscles. People, who suffer Achilles tendonitis usually are lack of flexibility and do not warm up the Achilles tendon before their activities.

2. Achilles tendon rupture

Inflammatory: inflammation and degeneration causing a series of microruptures of breakdown in the collagen fibers.

Poor nutrition: Inadequate vascularization 2-6 proximal to the insertion of the tendon.

Mechanical: Sudden push-off with the foot in the extension position, such as landing from a jump

Gradual pain and the pain worsens over time at back of the ankle is the most common sign of Achilles tendonitis. Signs and symptoms of Achilles tendonitis include:

Mild pain at the back of the ankle after running and other sports activities.

The pain is getting worse after prolonged running, tennis, stair climbing and jumping, or other activities. The patient has difficulty walking, stiffness, especially in the morning.

If partial tear, swelling and/or bump might show on the Achilles tendon, a crackling or creaking sound might be heard when touching or moving the Achilles tendon.

Rest: stop lower extremities sports such as running, biking, etc. for at least 2 to 4 weeks. You may continue upper extremities exercises, such as bench weight lift, etc.

Ice: as above

Compression: apply pressure on Achilles tendon with Ace bandage

Elevation: elevate the foot to avoid fluid retention

B: Avoid Anti-inflammation Medication such as Tylenol, Advil, etc. and pain killer, because Tylenol, Advil will not help heal the inflammation and pain killer may mask the pain and you may not be able to feel the pain and may injure your Achilles tendon more

You may put the heel lift simply inside your shoe or have a shoe wedge outside your shoe to help reduce the stretch of the Achilles tendon.

D: Surgery

Surgery is the last resort to repair your Achilles tendon.

Eric’s treatment:

Eric received physical therapy and acupuncture treatment from me for total 12 visits, he stopped sports related to the lower extremities. He also put ice on his Achilles tendon, and wedge into her shoes, she felt much better after the above treatment.